tbuckley/cabot-search huggingface dataset:
P12 A flare of dermatitis herpetiformis precipitated by etanercept
Authors: Elizabeth Wasson, Rosie Vincent, Michael Giles Dunhill
Journal: British Journal of Dermatology (2023)

Abstract We report the case of a 79-year-old man who presented with an acute, intensely pruritic, widespread rash, which, on examination, consisted of symmetrical, haemorrhagic nodules and vesicles with some desquamation affecting the extensor surfaces of the arms, flexor surfaces of the legs and the natal cleft. He had a history of coeliac disease (for which he had adhered to a strict gluten-free diet since 1997) and rheumatoid arthritis. He had his first dose of the anti-tumour necrosis factor (TNF) agent etanercept prior to this episode to manage his arthritis. A punch biopsy for histopathology showed subepidermal blisters with a predominance of neutrophils. Eosinophils were also present to the level of the eccrine coils within the dermis, with eosinophilic flame figures but no eosinophil spongiosis at the edges of the blister. Direct immunofluorescence showed granular IgM and IgA in the dermal papillae, and a similar reaction was seen with fibrinogen. These histological findings were strongly suggestive of dermatitis herpetiformis (DH). Owing to diagnostic uncertainty on presentation, initial treatment was with high-dose topical steroids and emollient. and a yellow card was completed. Since this presentation, he has had no further flares and has not required dapsone. Multidisciplinary team discussion decided that the patient should avoid other anti-TNF treatments, but he has found relief for multiple months with rituximab and has had no cutaneous adverse events on this agent. The aetiology of DH following anti-TNF treatment is not immediately clear. Increased immunogenicity and cytokine release have been hypothesized to be part of the pathology of many adverse reactions to anti-TNF agents. It is conceivable that the cytokine release ordinarily seen in DH is replicated by the administration of anti-TNF agents. There have been many cases of anti-TNF agents leading to worsening eczema and psoriasis. Interestingly, these conditions have been found to upregulate TNF-α, a feature that is also seen in DH. This appears to be the first case described in the literature of etanercept-induced DH. A reaction with infliximab was reported in 2008, with a similar rash and histology consistent with DH, but it differed as the patient had no prior diagnosis of coeliac disease and presented after their second dose (Marakli SS, Uzun S, Ozbek S, Tuncer I. Dermatitis herpetiformis in a patient receiving infliximab for ankylosing spondylitis. Eur J Dermatol 2008; 18:88–9).
DP02 (P30) Declining staff numbers and increasing workload: is there a solution?
Authors: Charlotte Wolfe, Rebecca Phillips, Dhruvkumar Laheru, Rachel Fisher
Journal: British Journal of Dermatology (2023)

Abstract Within the UK, there is a rapidly rising incidence of malignancies, including cutaneous cancers. Over 1 million new patients are referred to dermatology each year, and a large proportion requires a diagnostic or therapeutic biopsy. Dermatologists often rely on histopathology to confirm or diagnose cancers, determine margins and perform specialist testing. The increasing rates of cancers are adding significantly to the histopathology workload. According to the Royal College of Pathologists (RCPath), only 3% of departments report having adequate staff to meet clinical demand. There are a significant number of unfilled training posts and a concurrent retirement crisis, with 25% of all pathologists over 55 years old. It can take up to 15 years to train consultants, with the more experienced able to handle greater workloads. The lack of pathologists, with widespread vacancies, has a significant impact. The resulting costs to the health service of employing locums and outsourcing work has been estimated to be £27 million annually. For patients, the costs of these shortages mean delays in diagnosis and treatment. A RCPath key performance indicator advises that 80% of cases should be reported within 7–10 calendar days. Across dermatology departments, there is a wide reported variation in reporting times from 1 to 28 weeks. In 2019, the longest wait, on average, was 5.8 weeks. We surveyed 60 histopathology consultants across different National Health Service trusts in England to determine the reasons behind these delays. The survey response rate was 45%. The results showed that 78% of departments have unfilled posts, 83% have employed locum staff or outsourced reporting of skin biopsies in the last 5 years and only 20% are able to meet the RCPath guidance. Additionally, almost one-quarter reported that they have had complaints or serious incidences related to delayed dermatopathology reporting. Survey comments revealed many other areas of potential diagnostic delay from sample labelling and prioritizing to prolonged laboratory processing times, unclear pathways to expedite samples and lack of histopathology secretaries. This survey highlights the increasing workforce demands and emphasizes the need for innovative changes to avoid delays in patient care. Possible solutions to address increased workload in an understaffed environment include adequate secretarial support, increasing pathology pathway navigators who prioritize urgent cases, improving information technology services, digital slide reporting and developing artificial intelligence to screen samples. Increasing dermatopathology training and exposure to histopathology at a junior level is mandatory. Raising these issues and making them a key investment priority for the government is imperative.
DP23 Paraprotein negative Schnitzler syndrome: a new clinical entity?
Authors: Nicole Fagan, Niall Conlon, Katie Ridge
Journal: British Journal of Dermatology (2023)

Abstract Schnitzler syndrome (SchS) is a rare autoinflammatory condition with prominent cutaneous features. The genetic basis of the condition is not understood. The Strasbourg Criteria outline the clinical diagnosis of SchS, requiring an IgM or IgG monoclonal gammopathy and an urticarial rash (Simon A, Asli B, Braun-Falco M et al. Schnitzler’s syndrome: diagnosis, treatment, and follow-up. Allergy 2013; 68:562–8). We report two cases of SchS, the first with a 5-year delay in the development of a paraprotein and the second with complete absence of a paraprotein, despite 12 years of symptoms. Case one was a 47-year-old female who attended with a 4-year history of a dusky-red urticarial rash and polyarthralgia. Inflammatory markers were persistently raised, in the absence of any identified cause. Investigations demonstrated thrombocytosis, hypocomplementaemia and an isolated elevated IgM (3.07 g L–1), with no monoclonal band. Serum free light chain κ : λ ratio was normal. The patient had a working diagnosis of hypocomplementaemic urticarial vasculitis, despite skin biopsy demonstrating a lack of fibrinoid necrosis. She failed to improve symptomatically on high-dose antihistamines, corticosteroids or azathioprine and had minimal improvement with omalizumab. Repeat serum electrophoresis identified the development of a new IgM κ paraprotein 5 years after the initial symptom onset. Interleukin (IL)-1 blockade resulted in rapid clinical and biochemical improvement. Case 2 was a 55-year-old woman with a 4-year history of recurrent urticaria. A diagnosis of urticarial vasculitis was made; skin biopsy was incongruent but displayed a neutrophilic infiltrate. She had a poor response to high-dose antihistamines and withdrew from services for 3 years. Subsequent therapy with ciclosporin, azathioprine, omalizumab, dapsone and colchicine yielded no clinical benefit. Laboratory investigations repeatedly showed elevated inflammatory markers and an elevated IgA (3.9 g L–1) in the context of inflammatory bowel disease but no IgM or IgM paraprotein. Serum free light chain κ : λ ratio was normal. Clinical suspicion of an autoinflammatory condition was high given the longstanding treatment-resistant urticaria and systemic inflammation. A trial of IL-1 blockade led to immediate clinical and biochemical resolution. This treatment was continued and has resulted in the eradication of a cumulative 12 years of symptoms. There are several reports of SchS with no monoclonal band responding to IL-1 antagonism. As these cases do not fulfil the obligatory criteria for SchS, we propose a new clinical entity, paraprotein-negative IL-1-mediated inflammatory dermatosis (PANID). It is not yet clear if PANID is a precursor to SchS, although published cases demonstrating delayed paraprotein development could support this. Clinicians should consider this diagnosis in patients with treatment-refractory urticaria and systemic inflammation.
BT25 A survey of users of a regional dermatology advice and guidance service
Authors: Fiona Campbell, Kathryn Thomson, Caroline Love
Journal: British Journal of Dermatology (2023)

Abstract Electronic advice and guidance (A&amp;G) was implemented in our trust in April 2016. Referrals to this service steadily increased with weekly requests up to 313 (average 261) in 2022. We noticed that, increasingly, requests were being sent from allied health professionals or junior medical staff often for quite rudimentary dermatology. A survey was constructed to understand who is using our service, their level of dermatology training, whether there is discussion prior to sending A&amp;G and to examine user satisfaction. A survey link comprising 16 questions was attached to A&amp;G replies within a 12-week period from October 2022. In total, 144 responses were received. Most responders were regular users of the service, with 20% sending over six requests a month. Of those responding, 94 were fully trained general practitioners (GPs), with the others a mix of junior doctors, nurses and allied health professionals. Only 27.8% of referrers had discussed the case within primary care prior to sending the request; this included one-third of non-GPs. Levels of formal dermatology training among requestors are low, with 10.4% stating they have no formal dermatology training and 35.4% having training only within primary care. Eighty-five per cent stated they would like more dermatology training. Our department has developed online management guidelines for use in primary care. While 75.7% of those responding were aware of these guidelines, only 30.3% looked at these prior to sending the A&amp;G request. Most requesters found the A&amp;G process very easy, and 99.3% felt they received a satisfactory A&amp;G response. Only 28.4% of requests were converted to a referral. Additional comments from the responders were universally positive with the service repeatedly described as ‘excellent’. We have created an easy-to-use, valued and quick service, but this creates extra work within secondary care if cases are not discussed locally before requesting specialist input. Many may not have been referred to secondary care prior to electronic A&amp;G being established. We will discuss the issues this presents and ways we can address this to ensure we are providing the optimal A&amp;G service for those who really need it.
BH04 Review of a dermatology nurse-led hair service
Authors: Megan Mowbray, Emma Christie
Journal: British Journal of Dermatology (2023)

Abstract In 2017, our department was faced with a significant delay in new patient waiting times for the tertiary hair and nails clinic. A nurse-led service was developed to relieve this pressure. Within 18 months, the waiting list was much more manageable at less than 12 weeks, an improvement that has been maintained. The nurse-led service was designed predominantly to see and treat patients with alopecia areata. We present details of the nurse training and clinic setup. Three years after the setup of the nurse-led hair clinic, we reviewed this service. The aims of this review were to assess the capacity of the nurse-led hair clinic, the clinical outcome and the psychological impact. A review of all patients seen between November 2021 and October 2022 is presented. The total number of patients seen was 130. The majority had focal alopecia areata (90%). Clinical outcome measures were recorded using the Severity of Alopecia Tool score and Alopecia Areata Investigator Global Assessment. Psychological outcome measures were assessed using the Dermatology Life Quality Index and a patient questionnaire. The majority (72%) were treated with intralesional triamcinolone; 5% received a wig. The aim is to treat and discharge, while enabling easy access back into the service. It was hoped that this pathway would alleviate patient anxiety on discharge. All patients reported that they found it easy/very easy to be referred correctly by their general practitioner. The majority of returning patients had been given a clear explanation of the rereferral process on discharge. All reported an excellent or good service. More than 90% answered positively when asked whether the nurse listened, addressed fears/concerns and provided adequate verbal and written information. Sixty-two per cent remember being signposted to a relevant support group and all were satisfied with their treatment. We will present written information provided by the patients on what they found most useful about the clinic and how the clinic could be improved. We show the success of a nurse-led service that has addressed capacity issues and clinical management and provides emotional support. The detail presented will be sufficient to guide other departments on training and clinic setup when developing such a service.
P75 Are ‘hypoallergenic’ personal care products truly safe?
Authors: Siwaporn Hiranput, Lucy Smith, Paul Devakar Yesudian
Journal: British Journal of Dermatology (2023)

Abstract It is estimated that one-fifth of the general population may have allergic contact dermatitis (ACD) to common environmental allergens. Skincare companies are increasingly advertising their products as ‘hypoallergenic’, targeting consumers who seek personal care products (PCPs) that are less likely to cause an allergic reaction. However, there are no Food and Drug Administration standards to regulate the use of the term hypoallergenic, allowing manufacturers to use the term freely. We evaluated PCPs marketed as hypoallergenic from two health and beauty retailers in the UK for the presence of allergens in the British Society of Cutaneous Allergy (BSCA) baseline series. Product and ingredient lists were obtained from www.boots.com and www.superdrug.com in November 2022 using the term hypoallergenic in the search box. PCPs without the term hypoallergenic in the product description, unrelated products (plasters, jewellery, sanitary towels, tampons, clothing, facial brushes) and duplicates (same products in different sizes) were excluded. In total, 208 PCPs met the inclusion criteria: 47 (22.6%) were rinse-off and 161 (77.4%) were leave-on products. At least one substance from the BSCA baseline series was an ingredient in 79 (38.0%) PCPs. Of these, 54 (26.0%) had 1 potential allergen, 21 (10.2%) had 2, and 4 (1.9%) had 3 potential allergens from the series. The frequently encountered allergens were cetearyl alcohol and paraben mix, found in 42 (20.4%) and 37 (18.0%) of products, respectively. Other BSCA baseline series allergens identified in PCPs included 2-bromo-2-nitropropane-1,3-diol, lanolin, decyl glucoside, diazolidinyl urea, methylisothiazolinone, limonene and linalool. In addition, PCPs had chemicals that were related to and may cross-react with allergens in the BSCA baseline series. Parfum/fragrance, which can cross-react with fragrance mix I and II, was found in 85 (41.3%) PCPs. Sodium benzoate and/or benzoic acid, often used as preservatives in PCPs, were found in 66 (32.0%) products. Forty (19.4%) PCPs had ingredients that belong to the Asteraceae family and therefore may trigger an ACD in those with positive reaction to Compositae and/or sesquiterpene lactone mix. Twenty-three (11.2%) PCPs contained cetyl alcohol and/or stearyl alcohol, the two major components of cetearyl alcohol. Overall, 153 (74.3%) of 206 PCPs marketed as hypoallergenic contained BSCA baseline series allergens or ingredients that may cross-react with them. This highlights the need to increase public awareness and education about the potential dangers of purchasing ‘hypoallergenic’ PCPs.
CPC05 A case of extensive hypertrophic lupus erythematosus responsive to topical steroids
Authors: Sophie Diong, Graham Woods, Bairbre Wynne
Journal: British Journal of Dermatology (2023)

Abstract Hypertrophic lupus erythematosus (HLE) is a rare variant of lupus erythematosus, occurring in 2% of cases of chronic cutaneous lupus erythematosus (CCLE). It is an exaggerated proliferative epithelial response manifesting as verrucous-appearing hypertrophic indurated lesions occurring on sun-exposed sites. We present a case of the development of extensive HLE in a patient with subacute cutaneous lupus erythematosus (SCLE) with underlying pulmonary malignancy. A 74-year-old woman with Sjögren syndrome presented to dermatology with a 2-month history of a rash affecting her face and décolletage. Laboratory studies illustrated elevated antinuclear and anti-Ro antibodies. Biopsy from her chest confirmed SCLE. Malignancy screening revealed T1aN0 pulmonary lepidic adenocarcinoma, which was successfully managed with a lower lobectomy. Hydroxychloroquine was initially trialled but required discontinuation following intolerable side-effects. Mepacrine was then initiated, which allowed clearance of the rash, alongside yellow discoloration of the skin. Six months later, she developed a raised pruritic rash on her arms, legs and buttocks, resistant to current management alongside a trial of mycophenolate mofetil. Examination revealed violaceous hypertrophic plaques affecting 40% of her body-­surface area. The differential included hypertrophic lichen planus, nodular prurigo and HLE. Repeat lesional biopsies highlighted a lichenoid inflammatory infiltrate with overlying scale, favouring HLE. Owing to patient choice, topical mometasone furoate 0.1% was used to manage cutaneous disease, with a reduction in lesion size. HLE is a distinct subset of CCLE, regarded as a separate entity to SCLE. Twenty per cent of patients with SCLE also exhibit other types of cutaneous lupus erythematosus (CLE) lesions. No cases in the literature describe progression from SCLE to CCLE, or HLE, in particular. Hallmarks of HLE include verrucous lesions, chronicity and treatment resistance. Early recognition and follow-up are essential as malignancy may arise in long-standing lesions. Lung adenocarcinomas and hypertrophic lupus are both associated with p53 mutations and decreased granzyme B expression. Mutated p53 results in constitutive cell proliferation and DNA damage can accumulate in cells. Granzyme B is a protease in cytotoxic T cells involved in immune-mediated cell lysis. Both processes result in the potential to produce exaggerated hyperproliferative lesions, such as those observed in HLE and the lepidic adenocarcinomas. HLE is a rare clinical entity that can be easily misdiagnosed clinically and histopathologically. Increased awareness of this condition is essential to highlight the variety of clinical presentations of uncommon variants of CLE, to ensure they are considered while approaching clinical diagnosis.
PA28 Case series of concomitant use of propranolol and prednisolone in the treatment of ulcerated infantile haemangiomas and an updated literature review
Authors: Amanda Kuan, Mark Koh
Journal: British Journal of Dermatology (2023)

Abstract Infantile haemangiomas (IHs) are the most common benign tumours of infancy. Ten per cent of patients suffer complications, including ulceration, bleeding and functional impairment, and systemic treatment is required to reduce permanent disfigurement. Prednisolone was once the most commonly used and most efficacious treatment modality for complicated IHs, but propranolol has since overtaken its role as the first-line therapy in the last decade. In our practice, we have seen that propranolol monotherapy may not be sufficient in cases of IH with complex ulceration, and oral corticosteroids may serve as an effective adjunct in managing this group of patients. We present a case series of all patients diagnosed with ulcerated IH at KK Women’s and Children’s Hospital over the last 10 years. Fifteen patients were found to have ulcerated IHs. Eight patients were treated with both oral propranolol and oral prednisolone, and four patients were treated with oral propranolol alone. Patients were initiated on propranolol 1–2 mg kg−1 daily, and this dosage was titrated over an average of 9.6 months. Patients prescribed prednisolone had a tapering dosage starting from 0.5–2 mg kg−1 daily for 8–36 days. Average time to complete healing of ulcerated IHs in patients treated with both prednisolone and propranolol was 27.1 days, while patients treated with propranolol alone took 34 days. One patient had recurrence of ulceration after 2 months and had a second, 9-day course of prednisolone. None of the patients had complications from propranolol or prednisolone. Ulceration—the most common complication of IH—tends to heal poorly and is associated with pain, bleeding, infection and scarring. Early and efficacious treatment is needed to prevent functional impairment and permanent disfigurement. Several cases of ulcerated IH have been observed to be recalcitrant to propranolol monotherapy. In these patients, prednisolone used as an adjunct to propranolol has resulted in accelerated healing of these ulcerations. There are no guidelines on the dose and duration of prednisolone use, although a tapering dose starting at 1 mg kg−1 daily is usually given until complete healing of ulceration.
P86 Are symptoms of cardiac ischaemia different in patients who have psoriasis than in those who do not?
Authors: Sebastian Moshtael, Luigi Venetucci, Helen Young
Journal: British Journal of Dermatology (2023)

Abstract Patients with psoriasis have an increased risk of cardiovascular disease (CVD) for reasons that remain unknown. However, it may result from a complex interplay of contributory factors, including lifestyle and shared pathological mechanisms, as seen with other immune-mediated inflammatory diseases (IMIDs). Furthermore, in addition to epicardial coronary artery disease, patients with IMIDs have high levels of coronary microvascular dysfunction, which also contribute to cardiovascular morbidity and mortality. Our objective was to investigate whether the presentation of CVD may be different and therefore unrecognized in patients with psoriasis vs. those who do not have psoriasis. Sixty-six individuals with psoriasis and 112 age- and sex-matched individuals without psoriasis were recruited from the Chest Pain Clinic at a Regional Heart Care Centre. Traditional risk factors for CVD (smoking, body mass index, type 2 diabetes, blood pressure and lipid profile) were comparable between groups. Patients with psoriasis were statistically significantly older (P &amp;lt; 0.04) and more likely to have a family history of premature CVD (P &amp;lt; 0.01) than those without psoriasis. Individuals with psoriasis described poorly localized (P &amp;lt; 0.02), aching-type chest pain (P &amp;lt; 0.04) that radiated to the back (P &amp;lt; 0.01). The psoriasis group was significantly less likely to be investigated for coronary microvascular dysfunction with myocardial perfusion scanning (P &amp;lt; 0.002). However, 67% of patients with psoriasis were found to have flow-limiting disease (vs. 60% without psoriasis), classified as severe in 50% (vs. 43% without psoriasis), and were four times more likely to have two-vessel coronary disease, although this did not reach statistical significance. Individuals with both skin and joint psoriasis were more likely to have flow-limiting epicardial disease (14%) than those without arthropathy (10%; not significant). In conclusion, patients with psoriasis exhibit key differences in their presentation to heart care services than those who do not have psoriasis. Further research to individualize risk stratification for CVD in individuals with psoriasis is important.